Search

BACKGROUND AND AIMS: Many patients undergoing total pancreatectomy with islet autotransplant (TPIAT) for severe, refractory chronic pancreatitis or recurrent acute pancreatitis have a history of endoscopic retrograde cholangiopancreatography (ERCP). Using data from the multicenter POST (Prospective Observational Study of TPIAT) cohort, we aimed to determine clinical characteristics associated with ERCP and the effect of ERCP on islet yield. METHODS: Using data from 230 participants (11 centers), demographics, pancreatitis history, and imaging features were tested for association with ERCP procedures. Logistic and linear regression were used to assess association of islet yield measures with having any pre-operative ERCPs and with the number of ERCPs, adjusting for confounders. RESULTS: 175 (76%) underwent ERCPs [median number of ERCPs (IQR) 2 (1–4)]. ERCP was more common in those with obstructed pancreatic duct (p=0.0009), pancreas divisum (p=0.0009), prior pancreatic surgery (p=0.005), and longer disease duration (p=0.004). A greater number of ERCPs was associated with disease duration (p

Gastroparesis, which can be viewed as a syndrome featuring nausea, vomiting, and abdominal pain, and associated other symptoms and findings, is increasingly seen by surgeons. Gastroparesis is associated with a number of gastrointestinal anatomic and physiologic findings. This article reviews the use of bioelectric therapy of neuromodulation, via gastric electrical stimulation, for patients with drug refractory gastroparesis syndromes including surgical aspects of device placement and subsequent management. In addition to an overall approach to the placement and subsequent management of gastric electrical stimulation devices, several newer concepts are discussed. The role of pyloric dysfunction in gastroparesis is also discussed including how stimulation devices and pyloric therapies may be used in concert. The additions of full-thickness gastrointestinal biopsies along with other physiologic, including GI electrophysiology, as well as some serologic measures, are also discussed. In addition, evolving approaches and emerging technologies for bioelectric neuromodulation of the gastrointestinal tract are introduced. Gastroparesis syndromes can be approached in a systematic manner based on known pathophysiology and when indicated can be helped with surgical therapies including neuromodulation.

Artificial intelligence (AI) is emerging as a key component in diagnostic medical imaging, including echocardiography. AI with deep learning has already been used with automated view labeling, measurements, and interpretation. As the development and use of AI in echocardiography increase, potential concerns may be raised by cardiac sonographers and the profession. This report, from a sonographer's perspective, focuses on defining AI, the basics of the technology, identifying some current applications of AI, and how the use of AI may improve patient care in the future., Highlights • AI will have a strong role in echocardiography. • AI will guide image acquisition and optimization. • AI for image analysis may aid in interpretation. • AI is a tool that will not replace sonographers but will help them be more efficient.

Background: The International Study Group for Pancreatic Surgery provides globally accepted definitions for reporting of complications after pancreatic surgery. This International Study Group for Pancreatic Surgery project aims to provide a standardized framework for reporting of the results of operative treatment for chronic pancreatitis. Methods: An International Study Group for Pancreatic Surgery project circulation list was created with pre-existing and new members and including gastroenterologists in addition to surgeons. A computerized search of the literature was undertaken for articles reporting the operative treatment of chronic pancreatitis. The results of the literature search were presented at the first face-to-face meeting of this International Study Group for Pancreatic Surgery project group. A document outlining proposed reporting standards was produced by discussion during an initial meeting of the International Study Group for Pancreatic Surgery. An electronic questionnaire was then sent to all current members of the International Study Group for Pancreatic Surgery. Responses were collated and further discussed at international meetings in North America, Europe, and at the International Association of Pancreatology World Congress in 2019. A final consensus document was produced by integration of multiple iterations. Results: The International Study Group for Pancreatic Surgery consensus standards for reporting of surgery in chronic pancreatitis recommends 4 core domains and the necessary variables needed for reporting of results: clinical baseline before operation; the morphology of the diseased gland; a new, standardized, operative terminology; and a minimum outcome dataset. The 4 domains combine to give a comprehensive framework for reports. Conclusion: Adoption of the 4 domains of the International Study Group for Pancreatic Surgery reporting standards for surgery for chronic pancreatitis will facilitate comparison of results between centers and help to improve the care for patients with this debilitating disease.

Background Program directors use United States Medical Licensing Exam (USMLE) scores as criteria for ranking applicants. First-time pass rates of the American Board of Surgery (ABS) Qualifying (QE) and Certifying (CE) Examinations have become important measures of residency program quality. USMLE Step 1 will become pass/fail in 2022. Study design American Board of Surgery QE and CE success rates were assessed considering multiple characteristics of highly ranked (top 20) applicants to 22 general surgery programs in 2011. Chi-square, t-test, Wilcoxon Rank sum, linear and logistic regression were used, as appropriate. Results The QE and CE first attempt pass rates were 96% (235/244) and 86% (190/221), respectively. QE/CE success was not significantly associated with sex, race, research experience, or publications. Alpha Omega Alpha (AΩA) status was associated with success on the index CE (98% vs 83%; p = 0.008). Step 1 and Step 2 Clinical Knowledge (CK) scores of surgeons who passed QE on their first attempt were higher than scores of those who failed (Step 1: 233 vs 218; p = 0.016); (Step 2CK: 244 vs 228, p = 0.009). For every 10-point increase in Step 1 and 2CK scores, the odds of passing CE on the first attempt increased 1.5 times (95% CI 1.12, 2.0; p = 0.006) and 1.5 times (95% CI 1.11, 2.02, p = 0.008), respectively. For every 10-point increase in Steps 1 and 2CK scores, the odds of passing the QE on the first attempt increased 1.85 times (95% CI 1.11, 3.09; p = 0.018) and 1.86 times (95% CI 1.14, 3.06, p = 0.013), respectively. Conclusions USMLE Step 1 and Step 2 CK examination scores correlate with American Board of Surgery QE and CE performance and success. The USMLE decision to transition Step 1 to a pass/fail examination will require program directors to identify other factors that predict ABS performance for ranking applicants.

Circulating microRNAs (miRNAs) can be biomarkers for diagnosis and progression of several pathophysiological conditions. In a cohort undergoing total pancreatectomy with islet autotransplantation (TPIAT) from the multicenter Prospective Observational Study of TPIAT (POST), we investigated associations between a panel of circulating miRNAs (hsa-miR-375, hsa-miR-29b-3p, hsa-miR-148a-3p, hsa-miR-216a-5p, hsa-miR-320d, hsa-miR-200c, hsa-miR-125b, hsa-miR-7-5p, hsa-miR-221-3p, hsa-miR-122-5p) and patient, disease and islet-isolation characteristics. Plasma samples ( n = 139) were collected before TPIAT and miRNA levels were measured by RTPCR. Disease duration, prior surgery, and pre-surgical diabetes were not associated with circulating miRNAs. Levels of hsa-miR-29b-3p ( P = 0.03), hsa-miR-148a-3p ( P = 0.04) and hsa-miR-221-3p ( P = 0.01) were lower in those with genetic risk factors. Levels of hsa-miR-148a-3p ( P = 0.04) and hsa-miR-7-5p ( P = 0.04) were elevated in toxic/metabolic disease. Participants with exocrine insufficiency had lower hsa-miR-29b-3p, hsa-miR-148a-3p, hsa-miR-320d, hsa-miR-221-3p ( P < 0.01) and hsa-miR-375, hsa-miR-200c-3p, and hsa-miR-125b-5p ( P < 0.05). Four miRNAs were associated with fasting C-peptide before TPIAT (hsa-miR-29b-3p, r = 0.18; hsa-miR-148a-3p, r = 0.21; hsa-miR-320d, r = 0.19; and hsa-miR-221-3p, r = 0.21; all P < 0.05), while hsa-miR-29b-3p was inversely associated with post-isolation islet equivalents/kg and islet number/kg ( r = −0.20, P = 0.02). Also, hsa-miR-200c ( r = 0.18, P = 0.03) and hsa-miR-221-3p ( r = 0.19, P = 0.03) were associated with islet graft tissue volume. Further investigation is needed to determine the predictive potential of these miRNAs for assessing islet autotransplant outcomes.

Mesenchymal stem cells (MSCs) are proven to be beneficial in islet transplantation, suggesting a potential therapeutic role of them in total pancreatectomy with islet autotransplantation (TP-IAT) for chronic pancreatitis (CP) patients. We investigated whether MSCs derived from CP patients are suitable for use in autologous cell therapy. MSCs from healthy donors (H-MSCs) and CP patients (CP-MSCs) were studied for phenotype, colony formation potential, multilineage differentiation ability, proliferation, senescence, secretory characters, and immunosuppressive functions. The potential protective effect of CP-MSCs was evaluated on hypoxia-induced islet cell death. Cell surface markers were similar between H-MSCs and CP-MSCs, as well as the ability of colony formation, multilineage differentiation, secretion of vascular endothelial growth factor and transforming growth factor (TGF-β), senescence, and inhibition of T cells proliferation in vitro. We found that growth differentiation factor 6 and hepatocyte growth factor (HGF) were significantly downregulated, whereas TGFβ and matrix metalloproteinase-2 were significantly upregulated in CP-MSCs compared with H-MSCs, among 84 MSC-related genes investigated in this study. MSCs from CP patients secreted less HGF, compared with the H-MSCs. A higher interferon-γ-induced indoleamine 2,3-dioxygenase expression was observed in CP-MSCs compared to H-MSCs. Moreover, CP-MSCs prevented hypoxia-induced β cell deaths to a similar extent as H-MSCs. Regardless of moderate difference in gene expression, CP-MSCs possess similar immunomodulatory and prosurvival functions to H-MSCs, and may be suitable for autologous cell therapy in CP patients undergoing TP-IAT. Stem Cells Translational Medicine 2019;8:418–429

Background Best practice to select patients with chronic pancreatitis for surgical management with total pancreatectomy with islet autotransplantation (TPIAT) is in evolution as new discoveries are made in the pathogenesis of chronic pancreatitis. Study Design A prospectively maintained database of patients undergoing TPIAT was reviewed. Islet function was inferred from daily insulin requirement. Pain relief was evaluated by healthcare use and narcotic use. Quality of life (QOL) was measured with the RAND 12-Item Short Form Survey. Results One hundred and ninety-five patients (141 women, aged 40.3 years, BMI 26.5 kg/m 2 ) underwent TPIAT. Mean duration of disease before operation was 8.1 years. Fifty-six (29%) patients had pancreatic operations before TPIAT, 37 (19%) patients were diabetic preoperatively, and 52 (27%) patients were smokers. A mean of 3,253 islet equivalents transplanted/kg were harvested. Insulin independence was achieved in 29%, 28%, and 23% of patients at 1, 2, and 5 years postoperative. Nonsmokers with a shorter duration of chronic pancreatitis and no earlier pancreas operation were more likely to be insulin free. Median number of preoperative emergency department visits and hospitalizations were 6.6 and 4.3 annually, respectively, compared with 0 at 1, 2, and 5 years postoperative. Median oral morphine equivalents were 214 mg/kg preoperation and 60, 64, 69, at 1, 2, 5 years postoperative. Preoperative, 1, 2, 5 years postoperative QOL scores were 29, 36, 34, and 33 (physical; p Conclusions Total pancreatectomy with islet autotransplantation is a durable operation, with islet function, pain relief, and QOL improvements persisting to 5 years postoperative. Patients with genetic pancreatitis, short duration of disease, and nonsmokers have superior outcomes.

Islet engraftment after transplantation is impaired by high rates of islet/β cell death caused by cellular stressors and poor graft vascularization. We studied whether cotransplantation of ex vivo expanded autologous bone marrow‐derived mesenchymal stem cells (MSCs) with islets is safe and beneficial in chronic pancreatitis patients undergoing total pancreatectomy with islet autotransplantation. MSCs were harvested from the bone marrow of three islet autotransplantation patients and expanded at our current Good Manufacturing Practices (cGMP) facility. On the day of islet transplantation, an average dose of 20.0 ± 2.6 ×106 MSCs was infused with islets via the portal vein. Adverse events and glycemic control at baseline, 6, and 12 months after transplantation were compared with data from 101 historical control patients. No adverse events directly related to the MSC infusions were observed. MSC patients required lower amounts of insulin during the peritransplantation period (p = .02 vs. controls) and had lower 12‐month fasting blood glucose levels (p = .02 vs. controls), smaller C‐peptide declines over 6 months (p = .01 vs. controls), and better quality of life compared with controls. In conclusion, our pilot study demonstrates that autologous MSC and islet cotransplantation may be a safe and potential strategy to improve islet engraftment after transplantation. (Clinicaltrials.gov registration number: {"type":"clinical-trial","attrs":{"text":"NCT02384018","term_id":"NCT02384018"}}NCT02384018). stem cells translational medicine 2018;7:11–19

Stresses encountered during human islet isolation lead to unavoidable β-cell death after transplantation. This reduces the chance of insulin independence in chronic pancreatitis patients undergoing total pancreatectomy and islet autotransplantation. We tested whether harvesting islets in carbon monoxide-saturated solutions is safe and can enhance islet survival and insulin independence after total pancreatectomy and islet autotransplantation. Chronic pancreatitis patients who consented to the study were randomized into carbon monoxide (islets harvested in a carbon monoxide-saturated medium) or control (islets harvested in a normal medium) groups. Islet yield, viability, oxygen consumption rate, β-cell death (measured by unmethylated insulin DNA), and serum cytokine levels were measured during the peri-transplantation period. Adverse events, metabolic phenotypes, and islet function were measured prior and at 6 months post-transplantation. No adverse events directly related to the infusion of carbon monoxide islets were observed. Carbon monoxide islets showed significantly higher viability before transplantation. Subjects receiving carbon monoxide islets had less β-cell death, decreased CCL23, and increased CXCL12 levels at 1 or 3 days post transplantation compared with controls. Three in 10 (30%) of the carbon monoxide subjects and none of the control subjects were insulin independent. This pilot trial showed for the first time that harvesting human islets in carbon monoxide-saturated solutions is safe for total pancreatectomy and islet autotransplantation patients.

Gastroparesis is a condition characterized by impaired gastric motility that may result in weight loss and malnutrition. There have been promising studies demonstrating improvement in symptoms after gastric electrical stimulation (GES) implantation for medically refractory gastroparetics [1-10]. With the heterogeneous population of gastroparetics, the aim of this study was to assess if etiology correlated with response to GES.A retrospective review and analysis was performed on patients who underwent GES over a 10-year period at a single institution. Each patient was stratified into an etiological subset (diabetes, idiopathic, post-surgical). Patients were compared by demographics, medical and surgical history, subsequent GES explantation vs continued therapy, need for supplemental nutrition postoperatively, weight gain, weight loss or weight maintenance, and readmission rates.183 patients underwent GES from 2005 to 2015. 50% were diabetic (n = 91), 42% idiopathic (n = 76), and 9% post-surgical (n = 16). Diabetic patients (DM) demonstrated the highest likelihood of continued therapy compared to post-surgical (PS) and idiopathic patients (ID) (54.7% vs 9.5% vs 35.8%, respectively, p 0.05). DM patients saw a greater incidence of weight gain 4 kg, compared to PS and IS patients (67.6% vs 8.1% vs. 24.3%, respectively, p 0.05). ID patients were most likely to have it removed compared to DM and PS patients (65.7% vs 28.6% vs 5.7%, respectively, p = 0.05). PS patients were least likely to have their GES removed. They were also least likely to utilize supplemental nutrition compared to DM and ID (9.4% vs 49.1% vs 41.51%, respectively, p 0.05).Patients with gastroparesis had different clinical outcomes after GES therapy based on underlying etiology. By gaining a better understanding of the effects of GES, it can be offered to the appropriate patient.

The impact of lymph node (LN) status and lymphadenectomy (LA) on survival in pancreatic neuroendocrine tumors (pNETs) remains controversial. We evaluated the impact of tumor extension and grade on nodal metastasis and survival. Surgical pNET patients were queried in the Surveillance Epidemiology and End Results (SEER) database (1998–2012, N = 981). Factors associated with LN status were analyzed by logistic regression and by Cox analyses. For T1–T2 tumors, N status was associated only with tumor size. N status (p = 0.001), grade (p

Many patients with recurrent acute and chronic pancreatitis who are candidates for total pancreatectomy and islet cell autotransplantation (TPIAT) undergo endoscopic retrograde cholangiopancreatography (ERCP). However, little is known on the impact of ERCP on TPIAT outcomes. We aimed to explore the effect of antecedent ERCP on islet yield and postoperative insulin requirement after TPIAT.Through a prospectively maintained database, we identified patients who underwent TPIAT at our institution between 2009 and 2016. After adjusting for confounders, islet cell yield and postoperative insulin requirement were compared between subjects who did and did not undergo ERCP within 2 years prior to TPIAT.Data were available on 167 TPIAT patients during the study period; 105 (62.9%) had undergone ERCP within 2 years prior. Prior ERCP was not associated with a reduction in islet equivalents per patient kilogram (odds ratio, 1.37; 95% confidence interval, 0.75-2.5; P = 0.31). Antecedent ERCP was not associated with increased postoperative insulin requirement among patients with no diabetes undergoing TPIAT (odds ratio, 0.85; 95% confidence interval, 0.39-1.83; P = 0.67).Antecedent ERCP does not appear to have a deleterious impact on islet cell yield during TPIAT. Additional multicenter data are needed to more clearly determine the impact of ERCP in this context.

BACKGROUND: Chronic opiate use leads to a sensitized behavioral response to acute pain, which in turn, leads to escalating doses of opiates. This study was designed to test the hypothesis that chronic opiate usage is also associated with a sensitized neurobiological response to acute pain in individuals that have used prescription opiates for 6 or more months. METHODS: Fourteen patients with non-alcoholic chronic pancreatitis that have been taking prescription opiates for 6 or more months and 14 gender matched, non-opiate using controls were enrolled. Functional neuroimaging data was acquired while participants received blocks of thermal stimulation to their wrist (individually-tailored to their pain threshold). RESULTS: Self-reported pain was significantly greater in opiate using patients (3.4±3.4) than controls (0.2±0.8: Brief Pain Inventory p

Infiltrating macrophages can induce inflammation by secretion of proinflammatory cytokines and contribute to islet graft loss shortly after islet transplantation. In this study, we tested the mechanistic effects of AAT in mitigating macrophage mediated inflammation in an intrahepatic islet transplantation model in which human islets (2500 islet equivalent numbers) were transplanted into NOD-SCID mice that had been rendered diabetic (blood glucose >350mg/dl) by streptozotocin treatment. AAT (Prolastin-C, Grifols) was given to recipients intraperitoneally at 4 mg/mouse, every two days for 14 days, beginning before transplantation. In those recipients receiving AAT (n=29), 69.0% reached normoglycemia, compared to 35.7% in controls (n=28, p=0.002, logrank test) at 30 days post transplantation. Compared to mice treated with vehicle, AAT-treated mice had lower serum levels of interleukin 1 β (IL-1β), interferon- γ (IFN-γ) and interleukin 6 (IL-6), at day 1 post transplantation. To explore potential cell target(s) of AAT action, we analyzed activation of macrophages infiltrated into the liver after transplantation. Fewer M1 macrophages were observed in AAT-treated mice than in controls. To measure the effects of AAT on macrophage activation, we added AAT to Raw264.7 cells stimulated with IFN-γ in vitro. Expressions of M1 markers (iNOS, CD11c, TNFα, and IL-6) were dramatically decreased in AAT-treated cells compared to vehicle-treated controls. Co-culture of IFN-γ activated macrophages with islets led to islet cell apoptosis. Addition of AAT in the co-culture system reduced macrophage activation and protected islet cells from apoptosis. In summary, AAT treatment significantly enhances human islet graft survival and function after transplantation into the liver of NOD-SCID mice, in part by suppression of macrophage activation and pro-inflammatory cytokine production. Disclosure W. Gou: None. J. Wang: None. D. Kim: None. L. Song: None. C. Strange: Research Support; Self; Grifols, CSL Behring, Shire. Consultant; Self; Shire. Stock/Shareholder; Self; Abeona. Consultant; Self; CSL Behring. Research Support; Self; Adverum. Consultant; Self; Adverum. Research Support; Self; MatRx. D. Adams: None. K. Morgan: None. H. Wang: None.

The objective of this study was to assess the capacity of adipose-derived mesenchymal stem cells (ASCs) to mitigate disease progression in an experimental chronic pancreatitis mouse model. Chronic pancreatitis (CP) was induced in C57BL/6 mice by repeated ethanol and cerulein injection, and mice were then infused with 4 × 105 or 1 × 106 GFP+ ASCs. Pancreas morphology, fibrosis, inflammation, and presence of GFP+ ASCs in pancreases were assessed 2 weeks after treatment. We found that ASC infusion attenuated pancreatic damage, preserved pancreas morphology, and reduced pancreatic fibrosis and cell death. GFP+ ASCs migrated to pancreas and differentiated into amylase+ cells. In further confirmation of the plasticity of ASCs, ASCs co-cultured with acinar cells in a Transwell system differentiated into amylase+ cells with increased expression of acinar cell-specific genes including amylase and chymoB1. Furthermore, culture of acinar or pancreatic stellate cell lines in ASC-conditioned medium attenuated ethanol and cerulein-induced pro-inflammatory cytokine production in vitro. Our data show that a single intravenous injection of ASCs ameliorated CP progression, likely by directly differentiating into acinar-like cells and by suppressing inflammation, fibrosis, and pancreatic tissue damage. These results suggest that ASC cell therapy has the potential to be a valuable treatment for patients with pancreatitis.

The objective of this study was to test the hypothesis that distal pancreatectomy (DP) without intraperitoneal drainage does not affect the frequency of grade 2 or higher grade complications.The use of routine intraperitoneal drains during DP is controversial. Prior to this study, no prospective trial focusing on DP without intraperitoneal drainage has been reported.Patients undergoing DP for all causes at 14 high-volume pancreas centers were preoperatively randomized to placement of a drain or no drain. Complications and their severity were tracked for 60 days and mortality for 90 days. The study was powered to detect a 15% positive or negative difference in the rate of grade 2 or higher grade complications. All data were collected prospectively and source documents were reviewed at the coordinating center to confirm completeness and accuracy.A total of 344 patients underwent DP with (N = 174) and without (N = 170) the use of intraperitoneal drainage. There were no differences between cohorts in demographics, comorbidities, pathology, pancreatic duct size, pancreas texture, or operative technique. There was no difference in the rate of grade 2 or higher grade complications (44% vs. 42%, P = 0.80). There was no difference in clinically relevant postoperative pancreatic fistula (18% vs 12%, P = 0.11) or mortality (0% vs 1%, P = 0.24). DP without routine intraperitoneal drainage was associated with a higher incidence of intra-abdominal fluid collection (9% vs 22%, P = 0.0004). There was no difference in the frequency of postoperative imaging, percutaneous drain placement, reoperation, readmission, or quality of life scores.This prospective randomized multicenter trial provides evidence that clinical outcomes are comparable in DP with or without intraperitoneal drainage.

Cholecystectomy after endoscopic sphincterotomy (ES) is associated with improved outcomes compared to ES alone, however randomized trials have included mainly fit surgical candidates. Our objective was to assess the impact of cholecystectomy after ES among elderly patients, in whom the perceived risks of surgery may be increased and the prevailing bias may be to defer cholecystectomy.We performed adjusted analyses comparing clinical outcomes in patients ≥65 years of age who did and did not undergo follow-up cholecystectomy after endoscopic sphincterotomy for choledocholithiasis, ascending cholangitis, or gallstone pancreatitis. We also compared adverse events between the two groups.In the ES alone group, 39.3% of patients experienced a recurrent complication compared with 18.0% in the ES and cholecystectomy group. After adjusting for comorbidities using multivariable regression, cholecystectomy in addition to ES was associated with a reduced risk of recurrent choledocholithiasis (OR 0.38, 95%CI 0.34-0.42, P0.001), ascending cholangitis (OR 0.28, 95%CI 0.23-0.34, P0.001), and gallstone pancreatitis (OR 0.35, 95%CI 0.24-0.49, P0.001) compared to ES alone. This benefit was preserved after propensity score adjustment, in patients ≥75 years of age, and in those with major comorbidities including cancer, heart failure, and liver disease. Serious post-operative complications such as myocardial infarction, pulmonary embolism, and pneumonia were not more common in the cholecystectomy group.Among older patients, including those with serious comorbidities, cholecystectomy after endoscopic sphincterotomy was associated with a significant and clinically important reduction in recurrent complications compared to sphincterotomy alone. This benefit did not appear to be outweighed by surgical complications, highlighting the importance of cholecystectomy, even in elderly patients whose lifespans may be limited by unrelated conditions.

Objective The objective of this study is to assess clinical variables that may be associated with risk for opioid misuse in individuals with chronic pancreatitis. Design This study utilized a descriptive, quasi-experimental, cross sectional design. Setting and Patients Three hundred seven individuals with nonalcoholic chronic pancreatitis engaged in chronic opioid therapy for pain presented to an outpatient specialty clinic at an academic medical center. Measures Participants completed the Current Opioid Misuse Measure (COMM), Brief Pain Inventory (BPI), Short Form (SF)-12 Quality of Life Measure, Center for Epidemiological Studies 10-item Depression Scale (CESD), and a single item asking about current alcohol use. Mean scores on the CESD, COMM, BPI, SF-12, and factors associated with opioid misuse measures from regression analyses were the outcome measures. Results Mean scores on the CESD, COMM, BPI pain-on-average item, and the SF-12 physical and psychological quality of life factors (t scores) were 11.2 (standard deviation [SD] = 6.7), 8.5 (SD = 7.3), 4.8 (SD = 2.8), 39.7 (SD = 7.0), and 45 (SD = 9.0), respectively. Descriptive analyses revealed that 55% of participants scored above the clinical cutoff for depression on the CESD, and 39% scored above the cutoff for opioid misuse concerns on the COMM. Regression analyses identified several factors associated with higher opioid misuse measure scores, including increased depressive symptoms from the CESD (β = 0.38, P

The Culture of Peace News Network, an internet news service, is analyzed in the framework of a general approach to education for a culture of peace. Its format reflects the eight program areas for a culture of peace as adopted by the UN General Assembly. Among its other operating principles are universality of news with all cultures and regions of the world given equal priority, requirement that reflection be accompanied by action and that news should be positive and open to debate, that ‘slow news’ is as important as ‘fast news,’ and that readers should participate by writing as well as reading. The Network has yet to achieve its goal of forcing commercial media to consider actions for a culture of peace as newsworthy, but it is suggested that this will depend on the growth of the global movement for a culture of peace which remains rather small at the present time.

Previous studies have shown that total pancreatectomy with islet cell autotransplantation improves quality of life in chronic pancreatitis. A significant number of these patients develop postoperative hyperglycemia and daily insulin requirements or increase in daily insulin requirements. Our study investigates whether increased insulin requirements postoperatively have a negative impact on quality of life. A prospectively collected database of 74 patients undergoing extensive pancreatectomy with islet autotransplantation for pancreatitis was reviewed. Data pertaining to daily requirements and quality of life (QOL), as measured by the SF-12 questionnaire, in the preoperative and postoperative period were reviewed. Approval from the Institutional Review Board for the evaluation of human subjects was obtained. Seventy-four patients underwent extensive pancreatectomy with islet autotransplantation for pancreatitis. The majority of these patients required new daily insulin or an increase in daily insulin requirements post-operatively. Mean preoperative HA1c in this group was 5.6 with an increase to 7.3 at 6 months postoperatively ( P < 0.001), a mean of 8.1 at 12 months, and 8.9 at 2 years. Mean preoperative daily insulin requirements for this group were five units/day with average increase to 19 units/day at 6 months, 21 units/day at 12 months, and 26 units/day at 2 years. Preoperative QOL scores were a mean of 26 for the physical component and 36 for the mental health component. Postoperatively, physical component scores averaged 33 at 6 months (p < 0.001), 36 at 12 months, and 36 at 2 years; the mental health component scores averaged 42 at 6 months (p = 0.007), 41 at 12 months, and 41 at 2 years. There is no correlation between physical component score or mental component score QOL scores and daily insulin requirements ( r = -0.016 and r = 0.039, respectively). Total pancreatectomy with islet cell autotransplantation is an effective surgery for end-stage chronic pancreatitis. Quality of life significantly improves in physical and mental health components regardless of a postoperative increase in daily insulin requirements.

The Puestow procedure, also called lateral pancreaticojejunostomy, has been the mainstay of surgical therapy for dilated duct chronic pancreatitis for decades. Principles that Puestow and Gillesby described in 1958 are pertinent to the modern conduct of this operation that is described with current practice guidelines.

Total pancreatectomy with immediate islet autotransplantation (IAT) can be an effective therapy in patients with chronic pancreatitis. Patient selection criteria for radical resection are not well defined. The impact of prior pancreatic surgery on quality of life outcomes in patients undergoing IAT is evaluated. A retrospective review of a prospectively collected database of patients undergoing pancreatectomy with islet autotransplantation was undertaken. Patients having undergone prior pancreatic resection and/or drainage procedures were compared with those without prior pancreatic operative history. Sixty-one patients underwent pancreatectomy with IAT for pancreatitis. Twenty-three patients had a prior history of pancreatic surgery (Group S); 38 had no prior history of pancreatic surgery (Group NS). Demographics between the groups were similar. Patients in Group S took more daily oral morphine equivalents and had a lower psychological quality of life preoperatively. Operative times and blood loss were similar between the patient groups. Islet yields were lower for patients in Group S. Postoperatively, daily insulin requirements at 6 months and 1 year trended higher in Group S. Postoperative quality of life scores at 6 months were improved and similar between the groups. Quality of life metrics continued to improve beyond 1 year of follow-up, with a trend toward greater improvement in the NS Group. Total pancreatectomy for chronic pancreatitis improves quality of life in patients with and without a prior history of pancreatic surgery. This study demonstrates that IAT without preceding pancreatic surgery may enhance outcomes measured by long term insulin requirements and quality of life.

In selected patients with chronic pancreatitis, total pancreatectomy with islet autotransplantation can be effective for the treatment of intractable pain while ameliorating postoperative diabetes. Improved quality of life scores and decreased daily narcotic use, as indicators of successful pain relief, are expected after total pancreatectomy. These outcomes and their relationship have not been well examined in this patient group. A prospectively collected database of patients undergoing extensive pancreatectomy with islet autotransplantation for pancreatitis was reviewed. Data pertaining to daily oral morphine equivalents (MEs) and quality of life (QOL), as measured by the SF-12 questionnaire, in the preoperative and postoperative period were reviewed. Approval from the IRB for the evaluation of human subjects was obtained. Over a 20-month period, 33 patients (25 women, median age 42) underwent extensive pancreatectomy with islet autotransplantation for pancreatitis. Mean follow-up was 9 months with a range of 6–12 months. Postoperative complications occurred in 16 patients (48%). Preoperative QOL scores were a mean 25 for physical component and 32 for mental health component. Postoperatively, physical component scores averaged 33 at 6 months (p = 0.025) and 36 at 12 months (mean increase of 11); the mental health component scores averaged 43 at 6 months (p = 0.007) and 44 at 12 months (mean increase of 12). Preoperative MEs averaged 357 mg daily. At discharge from the hospital, this number increased to 536 mg average MEs daily, a 50% increase, as expected after major surgery in the chronic pain patient. At 6 months, 15 out of 31 patients (48%) required less daily MEs than preoperatively and averaged 161 mg daily (−55%). By 12 months, 11 out of 17 patients (65%) required less daily MEs than preoperatively and averaged 128 mg daily (−64%); four were narcotic-free (23%). Of the six patients who did not decrease their analgesic requirements at 1 year, five (83%) still had an improved physical QOL score (one patient was unchanged) and all six had an improved mental health QOL. Total pancreatectomy with islet autotransplant is an effective surgery for end-stage chronic pancreatitis. Quality of life improves early postoperatively while decreased narcotic analgesia requirements occur later. Both improved quality of life and decreased narcotic analgesia requirements continue to occur at least up to 1 year postoperatively. Further investigation is needed to assess the durability of total pancreatectomy with islet autotransplantation for severe chronic pancreatitis with respect to pain relief and improved quality of life.

Laparoscopic cholecystectomy (LC) has served as the igniting spark in the laparoscopic surgery explosion; however, it is unclear who created the spark. The question remains: Who did the first LC?

Background and Aims ERCP has largely replaced common bile duct exploration for therapy of common bile duct pathology, yet its use as a purely diagnostic test has declined. Among inpatients, we hypothesized that timing between ERCP and cholecystectomy (CCY) has changed. The objectives were to measure temporal trends in the timing between inpatient ERCP and CCY and to examine factors associated with delays. Methods We used the National Inpatient Sample between 1998 and 2013 to classify admissions for gallstone-related diagnoses undergoing inpatient CCY and ERCP by timing relative to CCY: within (±) 1 day, ≥2 days before, and ≥2 days after. Logistic regression and Poisson regression were used to determine pattern utilization and association of ERCP timing on hospital length of stay. Results Between 1998 and 2013, the proportion of admissions for CCY associated with same-stay ERCP increased (14.5% in 1998 to 17.3% in 2013, P Conclusions Use of inpatient ERCP in conjunction with CCY has increased minimally between 1998 and 2013, whereas length of stay has decreased. ERCPs performed within 1 day of CCY were associated with shorter hospital length of stay, suggesting delays between inpatient procedures should be minimized unless medical comorbidities preclude it.

Cystic lesions of the pancreas are identified with increasing frequency by modern imaging. The mucinous cystic neoplasm (MCN) is treated with resection for its malignant potential. How much preoperative evaluation is needed before undertaking operation is frequently a diagnostic dilemma. A retrospective review of 32 patients who underwent resection of a MCN between 1994 and 2007 was performed to define the preoperative evaluation and operative treatment of MCN patients. Thirty-two patients (30 women; mean age 49) had histology-proven MCN. Twenty-seven patients had symptomatic cysts (84%). Five had a history of gallstones and/or acute pancreatitis. All patients were worked up with CT and/or MRI. Endoscopic ultrasound was performed in 14 (44%) and endoscopic retrograde cholangiopancreatography in six (18%). Cytology was obtained in 13 (40%). Pathology revealed 22 benign MCNs (68%), five malignant MCNs (16%), and five MCNs with borderline pathology. Preoperative workup including CT or MRI imaging and cytology suggested MCN as the lesion in 15 patients (46%). CT features by itself predicted MCN in three patients (9%). Cytology revealed another six patients (19%) with possible MCN. In this series, preoperative workup did not identify three of five patients with MCN malignancy. A preoperative diagnosis cannot be made in most patients with MCN. Operative treatment can be based on clinical presentation and CT imaging because endoscopic ultrasound and fine needle aspiration for evaluation may be misleading. Middle-aged women with cystic lesions in the tail of the pancreas without prior gallstone or pancreatitis history most typically fit the profile of the MCN patient.

Pancreatic pseudocysts represent the majority of cystic lesions, and can usually be differentiated from cystic neoplasms, which have malignant potential. Endoscopic retrograde cholangiopancreatography (ERCP) can help in solving diagnostic dilemmas. When ERCP demonstrates cyst communication with the pancreatic duct, the diagnosis of pseudocyst is usually secure. There are exceptions, however, as reported in these two case reports. A retrospective chart review was conducted of two patients undergoing distal pancreatectomy in 2008 to 2009 for cystic lesions communicating with the main pancreatic duct on ERCP. Both patients were women (ages 37 and 42) with a history of chronic abdominal pain and pancreatitis. Radiologic imaging showed cystic lesions in the pancreatic tail. ERCP demonstrated main pancreatic duct communication. When endoscopic management failed, surgical therapy was undertaken. Both patients underwent distal pancreatectomy with splenectomy. Pathologic findings were mucinous cystadenoma. The conventional wisdom that a pancreatic cyst communicating with the main pancreatic duct is a benign pseudocyst is not always wise. As seen in this series, mucinous cystadenomas can erode into the main pancreatic duct. Women in the fourth and fifth decade with symptomatic cysts in the pancreatic tail with a history of pancreatitis should undergo distal pancreatectomy, regardless of ductal communication on ERCP.

Damage control laparotomy (DCL) has been a major advance in modern trauma care. The principles of damage control which include truncation of operation to correct acidosis, hypothermia, and coagulopathy with subsequent planned definitive repair are applicable in managing patients undergoing abdominal operations. In order to define indications, technique, and outcome, we undertook a retrospective review and analysis of pancreatic surgery patients in whom DCL was utilized.In a cohort of 835 patients who underwent elective pancreatic operations at the Medical University of South Carolina from 2001 to 2007, eight patients were identified who required DCL. Under Institutional Review Board approval, records were reviewed to define intraoperative blood loss, acidosis, hypothermia, coagulopathy, operative techniques, timing of definitive operation, and hospital outcome.There were five men and three women with a mean age of 51 years. The diagnosis was chronic pancreatitis in seven patients and cancer in one. The index operation was pancreatoduodenectomy in four patients, distal pancreatectomy in three, and total pancreatectomy in one. In four patients undergoing elective pancreatic resection intraoperative portal vein hemorrhage initiated damage control laparotomy. Four patients had damage control utilized at reoperation for abdominal sepsis (two) and hemorrhage (two). DCL techniques included external tube drainage (eight), abdominal packing (seven), staple closure of open bowel (four), and rapid abdominal closure (four). Operative blood loss ranged from 300 to 12,000 cc. Operative transfusions ranged from 0 to 44 U of packed red cells. Intraoperative INR was greater than 1.5 in four patients, pH ranged from 7.08 to 7.45, and temperature ranged from 34.8 to 38.8 degrees C. Laparotomy for pack removal and intestinal reconstruction was undertaken 1 to 7 days after DCL. Length of hospital stay ranged from 7 to 80 days. Hospital mortality was zero.Patients with exsanguinating hemorrhage and severe sepsis related to pancreatic surgery can be successfully managed with principles of DCL. Truncation of operation with abdominal packing, bowel closure, external drainage of bile and pancreatic ducts, and rapid abdominal closure with planned subsequent completion laparotomy should be considered in pancreatic operations when patients risk intraoperative acidosis, hypothermia, and coagulopathy due to sepsis or hemorrhage.

Background Patients who have undergone Roux-en-Y gastric bypass for morbid obesity may develop postoperative abdominal pain disorders that require surgical evaluation. Chronic pancreatitis and pain associated with sphincter of Oddi dysfunction (SOD) is an uncommon disorder whose clinical diagnosis is problematic without sphincter of Oddi manometry. To evaluate the diagnosis and treatment of SOD in the gastric bypass population, a retrospective review and analysis of gastric bypass patients who had undergone transduodenal sphincteroplasty (TS) for SOD was undertaken. Methods The medical records of patients who had undergone TS after gastric bypass at the Medical University of South Carolina Digestive Disease Center from January 2002 to December 2006 were evaluated for outcomes-based data with the approval of the institutional review board for the evaluation of human subjects. Long-term patient outcomes were assessed using the Medical Outcomes Study Short Form 36-item, version 2, quality-of-life survey. Results A total of 16 women (median age 49 years) were identified who had undergone TS with biliary sphincteroplasty and pancreatic ductal septoplasty for SOD. The indications for surgery included pain (100%), nausea (31%), weight loss (13%), and recurrent pancreatitis (31%). The diagnosis of SOD was supported by magnetic resonance cholangiopancreatography with secretin stimulation. Three postoperative complications (18.8%) developed, but no mortality. The average length of hospital stay was 5 days (range 2–9). Of the 16 patients, 13 (81%) responded to the survey follow-up. The mean length of follow-up was 28 months (range 16–57). Of the 13 patients, 11 (85%) reported pain improvement after surgery. The survey's norm-based scores were similar to those of a representative population. Conclusion SOD should be considered in the differential diagnosis of gastric bypass patients with pancreatobiliary pain after cholecystectomy. When the clinical history is supported by laboratory and magnetic resonance cholangiopancreatography data, TS can be undertaken with low morbidity and good patient outcomes. SOD is a notable disorder in the gastric bypass population. With appropriate patient selection, TS can be beneficial.

Most perforations of the gastrointestinal tract during endoscopic retrograde cholangiopancreatography (ERCP) can be managed nonoperatively. Identifying patients who require operative management is problematic. A clinical endoscopy database was queried for patients who sustained ERCP perforation over a 13-year period. Records were reviewed and analyzed with approval of the Institutional Review Board. During the study period, 12,817 patients underwent ERCP; 24 (0.2%) had an endoscopic perforation. Twelve patients had a retroperitoneal perforation during sphincterotomy and all were successfully managed nonoperatively. Nine of these were undergoing treatment for sphincter of Oddi dysfunction. Twelve patients had perforation remote from the papilla. Of these, 10 required surgical intervention. Six patients had surgically altered anatomy (three postpancreaticoduodenectomy, three post-Billroth II gastrectomy) and one had situs inversus. Six of these seven required surgical intervention. Median length of stay of all patients was 7.5 days, morbidity was 25 per cent, and one patient died 16 days after surgery. Gut perforation after ERCP requires prompt surgical evaluation. Patients with sphincterotomy-related retroperitoneal perforation can be managed safely with nonoperative therapy in most instances. Patients with remote perforation usually need surgical intervention. Altered foregut anatomy leads to injuries that usually require operative management.

The morbid obesity epidemic in the United States has resulted in increasing numbers of patients who have undergone Roux-en-Y gastric bypass who require surgical management of nonbariatric disorders. When pancreatic resection is indicated in bariatric patients, consideration of the altered foregut anatomy can be applied to the principles of pancreatic resection to foster effective techniques that minimize operative complications. A retrospective review and analysis of bariatric patients who underwent pancreatic resection at the Medical University of South Carolina Digestive Center over a 2-year period (2006 to 2007) was conducted to assess indications for operation, operative techniques, and postoperative outcome in patients with previous Roux-en-Y gastric bypass. There were five patients (four female, one male) identified with a mean age of 35 years (range, 32–50 years). The mean time interval from gastric bypass to pancreatic resection was 42.6 months (range, 10–72 months). Indications for pancreatic operations were islet hyperplasia in two patients, chronic pancreatitis in two, and serous cystadenoma in one. Two patients underwent duodenal-preserving pancreatic head resection (Beger procedure) and three underwent distal pancreatectomy and splenectomy. Mean length of hospital stay was 11.4 days (range, 5–22 days). Two patients had extended hospital stay as a result of gastrointestinal ileus. There was no other operative morbidity or mortality. Mean length of patient follow up was 9.8 months (range, 1–17 months). Specific operative techniques used in pancreatic head resection were duodenal preservation, pancreatic drainage with an omega loop constructed from a mid-Roux limb, and excluded stomach gastrostomy. Techniques used in pancreatic tail and body resection were splenectomy discontinuous from pancreatectomy, division of the splenic vein and artery at the pancreatic neck early in surgery, retrograde dissection of the pancreas body and tail, and dissection of the body and tail posterior to the Roux limb leaving the Roux limb intact. Pancreatic resection after Roux-en-Y gastric bypass is safe and effective when using prescribed operative principles that minimize disruption of the foregut reconstruction and adds protection to the gastric remnant with a gastrostomy for decompression and access for enteral alimentation when necessary.

Long-term excessive alcohol consumption is the most common risk factor for the development of chronic pancreatitis. Management of patients with alcohol-associated chronic pancreatitis can be complicated by problems associated with dependency, psychosocial burden, and physical changes like malnutrition and hepatic insufficiency. The records of 372 consecutive patients who underwent lateral pancreaticojejunostomy (LPJ, n = 184), pancreatoduodenectomy (PD, n = 97), or distal pancreatectomy (DP, n = 91) for chronic pancreatitis were retrospectively analyzed. Long-term outcome was assessed by patient survey with a median follow up of 5.5 ± 0.2 years. Of 372 patients, 171 underwent surgery for alcohol-associated chronic pancreatitis. According to patient questioning, the prevalence of alcohol cessation before surgery in the 171 patients was 81 per cent. Operative morbidity in the 171 patients was 20 per cent, 50 per cent, and 26 per cent after LPJ, PD, and DP, respectively, with an overall perioperative mortality rate of 2 per cent. None of the patients developed delirium tremens using an alcohol withdrawal protocol. Continued alcohol abuse before surgery did not affect perioperative morbidity ( P > 0.05). Follow up was available for a total of 229 patients, of which 39 per cent with alcohol-associated chronic pancreatitis had died compared with 16 per cent in the nonalcohol group ( P < 0.001). Of the remaining 171 patients, 45 per cent with alcohol-associated chronic pancreatitis had good pain control compared with 49 per cent of the remainder ( P > 0.05). Continuation of alcohol abuse after operation did not affect success for pain control at follow up ( P > 0.05). Surgical treatment of alcohol-associated chronic pancreatitis can be performed with similar morbidity and mortality compared with other forms of chronic pancreatitis. Alcohol cessation is preferred but not mandated to achieve good operative long-term outcome. Caution needs to be taken to prevent postoperative alcohol withdrawal. Long-term follow up with psychosocial support and management of co-existing addictions is important.

Background Surgical management of sphincter of Oddi dysfunction and pancreas divisum is controversial. In the modern era of therapeutic endoscopy, pain persisting despite endoscopic sphincterotomy and anatomy that makes the ampulla endoscopically inaccessible prompt referral for surgical transduodenal sphincteroplasty (TS). A retrospective review of sphincter of Oddi dysfunction and pancreas divisum patients who underwent TS for refractory pain in a recent time period was undertaken. Study Design The medical records of all patients who underwent TS for sphincter of Oddi dysfunction and pancreas divisum at the Medical University of South Carolina between January 2001 and December 2005 were reviewed. Longterm outcomes were assessed by a standardized written questionnaire and the SF-36 version 2 Quality of Life Survey. Results Sixty-eight patients underwent TS (median age 43 years, 54 women). Fifty-one had earlier endoscopic sphincterotomy; 17, with previous gastric surgery, did not. Operative morbidity was 10.3%, with no mortality. Forty-five patients (66%) completed the questionnaire; 62% had improvement in pain, without reintervention, over a median followup of 42.5 months (range 16 to 75 months). There was a trend toward more favorable outcomes in patients with earlier gastric surgery (no previous endoscopic sphincterotomy) compared with others (90% versus 54%, p=0.06). Multivariate analysis showed chronic pancreatitis (odds ratio 0.11 [95% CI 0.02 to 0.68; p=0.02]) and younger age (odds ratio 3.9 [95% CI 1.32 to 11.53; p=0.01] per decade) were independent predictors of poorer outcomes. Conclusions Good longterm outcomes with low operative morbidity can be obtained with TS in selected patients, including those with postgastric bypass, but younger age and chronic pancreatitis appear to predict poorer outcomes.

Obesity can cause insulin resistance and type 2 diabetes. Moderate elevations in bilirubin levels have anti-diabetic effects. This study is aimed at determining the mechanisms by which bilirubin treatment reduces obesity and insulin resistance in a diet-induced obesity (DIO) mouse model. DIO mice were treated with bilirubin or vehicle for 14 days. Body weights, plasma glucose, and insulin tolerance tests were performed prior to, immediately, and 7 weeks post-treatment. Serum lipid, leptin, adiponectin, insulin, total and direct bilirubin levels were measured. Expression of factors involved in adipose metabolism including sterol regulatory element-binding protein (SREBP-1), insulin receptor (IR), and PPARγ in liver were measured by RT-PCR and Western blot. Compared to controls, bilirubin-treated mice exhibited reductions in body weight, blood glucose levels, total cholesterol (TC), leptin, total and direct bilirubin, and increases in adiponectin and expression of SREBP-1, IR, and PPARγ mRNA. The improved metabolic control achieved by bilirubin-treated mice was persistent: at two months after treatment termination, bilirubin-treated DIO mice remained insulin sensitive with lower leptin and higher adiponectin levels, together with increased PPARγ expression. These results indicate that bilirubin regulates cholesterol metabolism, adipokines and PPARγ levels, which likely contribute to increased insulin sensitivity and glucose tolerance in DIO mice.

A terminal benign biliary stricture (BBS) is a common complication of chronic pancreatitis (CP). Historically, BBS was a surgical disease, treated with operative biliary bypass. With the advent of endoscopic retrograde cholangiopancreatography and endoscopic stenting, therapeutic endoscopy has become the primary approach to BBS. Endoscopic management has limitations, however, including unsatisfactory long term durability. Improvements in stent technology and technique are promising. Surgery can often concomitantly best address other CP related complications including pain. Surgery has higher short term morbidity but may be more durable long-term. Minimally invasive techniques in biliary bypass are feasible.

Malnutrition, intestinal dysmotility, and gastroparesis are frequent problems in patients with chronic pancreatitis who undergo pancreaticoduodenectomy. This has led to the practice of operative placement of enteral feeding tubes. The purpose of this study is to examine the efficacy of feeding tubes placed during pancreaticoduodenectomy in patients with chronic pancreatitis. The records of 78 consecutive patients who underwent pancreaticoduodenectomy for chronic pancreatitis were retrospectively reviewed and analyzed. Forty-nine patients who received feeding tubes at the time of operation were compared with 29 who did not have feeding tubes placed. Both groups had similar disease progress measured by duration of symptoms and preoperative nutritional status. During the observation period, there was a trend toward not using operative feeding tubes (first 6 years 84 per cent versus last 2 years 33%). The overall complication rate after pancreaticoduodenectomy was 54 per cent. Placement of a feeding tube was associated with an increase in intra-abdominal morbidity from 34 per cent to 57 per cent ( P < 0.03). None of the patients had a complication directly related to placement of the feeding tube. Eighty-eight per cent of the placed feeding tubes were used. Despite feeding tube placement, 49 per cent of patients with feeding tubes required postoperative use of total parenteral nutrition compared with 55 per cent of patients without feeding tubes ( P > 0.05). Length of hospital stay and hospital readmission during the first postoperative year were not affected by feeding tube placement. In conclusion, simultaneous feeding tube placement along with pancreatic head resection for chronic pancreatitis can be performed safely. The majority of the feeding tubes are used in postoperative care, but they do not prevent the need for total parenteral nutrition and do not shorten length of hospital stay.

There is increasing interest in implementing comprehensive perioperative protocols, including preoperative optimization and education, perioperative goal-directed fluid management, and postoperative fast tracking, to enhance recovery after surgery. Data on the outcomes of these protocols in pancreatic surgery, however, are limited.A retrospective review of a prospectively maintained pancreas surgery database at a single institution from August 2012 to April 2015 was undertaken. An enhanced recovery protocol was initiated in October 2014, and patients were divided into groups according to preprotocol or postprotocol implementation. Preoperative, intraoperative, and postoperative data were tabulated. Statistical analysis was performed with Student's t-test and Fisher's exact tests, as well as equality of variances where appropriate, using SAS System software (SAS Institute).Three hundred and seventy-eight patients (181 men, mean age 54 years, BMI 28 kg/m(2)) underwent elective pancreatic surgery during the study period, 297 patients preprotocol and 81 postprotocol. There were no significant differences in preoperative or intraoperative characteristics. Mean postoperative length of stay was significantly lower in the Enhanced Recovery After Surgery group (7.4 vs 9.2 days; p0.0001). Hospital costs were similarly lower in the Enhanced Recovery After Surgery group ($23,307.90 vs $27,387.80; p0.0001). Readmission (29% vs 32%) and pancreatic fistula (26% vs 28%) rates were similar between groups. Delayed gastric emptying was lower in the Enhanced Recovery After Surgery group (26% vs 13%; p = 0.03).Implementation of an enhanced recovery after pancreatic surgery protocol significantly decreased length of stay and hospital cost without increasing readmission or morbidity. Despite patient complexity and the potential need for individualization of care, enhanced recovery protocols can be valuable and effective in high-risk patient populations, including pancreatic surgery patients.

BackgroundCombined multichannel intraluminal impedance-pH (MII-pH) monitoring detects gastro-oesophageal reflux and identifies acid and non-acid reflux events. It can be used in patients with persistent symptoms on proton-pump inhibitor (PPI) therapy. The aim of this study was to assess laparoscopic Nissen fundoplication as a treatment for patients with persistent symptoms associated with reflux despite acid suppression documented by MII-pH monitoring.MethodA prospectively maintained database identified patients with persistent symptoms of gastro-oesophageal reflux disease despite PPI therapy who had undergone MII-pH monitoring and this was cross-referenced with patients who had undergone fundoplication at this institution. Follow-up after fundoplication was by periodic telephone interview and review of clinical records.ResultsOf 200 evaluated patients, 19 (14 female; mean age 40 (range 0.7–78) years) underwent laparoscopic Nissen fundoplication. Before surgery, 18 of 19 patients had a positive symptom index (at least half of symptoms associated with reflux) and one, a negative symptom index. After a mean follow-up of 14 (range 7–25) months, 16 of 17 (94 per cent) patients with a positive symptom index were asymptomatic or markedly improved (one patient was lost to follow-up). Persistent symptoms occurred in the patient with a negative symptom index, and one patient had recurrent symptoms after 9 months.ConclusionPatients with a positive symptom index resistant to PPIs with non-acid or acid reflux demonstrated by MII-pH monitoring can be treated successfully by laparoscopic Nissen fundoplication.

As morbidity and mortality rates for pancreatic surgery have improved over the past decades, patients with major medical comorbidities have been considered for operative treatment. The influence of poor health status on operative morbidity in patients with chronic pancreatitis is evaluated in this study. The records of 313 consecutive patients who underwent pancreaticoduodenectomy (n = 78), distal pancreatectomy (n = 83), or lateral pancreaticojejunostomy (n = 152) for chronic pancreatitis were retrospectively reviewed and analyzed. Patients’ risk for adverse outcome resulting from overall health status was audited using age, comorbidities, and Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) physiological score. Univariate analysis showed that patient's age did not contribute to change in morbidity (odds ratio [OR] = 1.01, P = 0.59). The presence of cardiac disease but not other comorbidities increased adverse outcome affected the need for intensive care unit stay and length of hospital stay (morbidity: 29% vs. 51%, OR = 2.6, P = 0.003). POSSUM physiological score was associated with an increase in morbidity and mortality (morbidity: OR = 1.16, P = 0.001; mortality: OR = 1.49, P = 0.001), in particular intraabdominal abscesses. Multivariate analysis showed that the only variable independently correlating with perioperative complications was POSSUM physiological score. Single comorbidities do not independently influence outcome after operations for chronic pancreatitis. A combination of several comorbidities is associated with an increase in postoperative infectious morbidity and mortality. High-risk patients should not be excluded from operative treatment, but need to be closely selected on a case-by-case basis.

Protein-energy malnutrition is a notable problem in the management of patients with chronic pancreatitis. The effect of malnutrition on pancreatic surgery is not well known. The records of 313 consecutive patients who underwent lateral pancreaticojejunostomy (LPJ, n = 152), pancreaticoduodenectomy (PD, n = 78), or distal pancreatectomy (DP, n = 83) for chronic pancreatitis were retrospectively reviewed and analyzed. Subjective Global Assessment, Nutritional Risk Index, and Instant Nutritional Assessment were used to assess the nutritional state. An average of all three nutritional indexes was established, and patients were categorized into well nourished (n = 101) as well as mild (n = 91), moderate (n = 94), and severe malnourished (n = 27). Poor nutritional state was associated with an increase in postoperative complication rate (LPJ: well nourished 14%, mild 25%, moderate 31%*, severe 50%*; PD: well nourished 44%, mild 44%, moderate 60%, severe 88%*; DP: well nourished 17%, mild 13%, moderate 30%, severe 55%*;*P < 0.045 vs well nourished). Low serum albumin levels also increased operative morbidity. The increase in morbidity was reflected by a higher rate of infectious complications as well as increased ICU stay. Body mass index and weight loss did not contribute to change in outcome. Malnutrition was associated with a higher incidence of postoperative complications after surgery for chronic pancreatitis. An increase in operative morbidity might be related to decreased protein synthesis and impaired immunocompetence.

Optimization of aircraft-stiffened composite panel structures often results in manufacturing incompatibilities between adjacent panels. Using genetic algorithms to optimize local panel stacking sequences allows panel populations of stacking sequences to evolve in parallel and send migrants to adjacent panels so as to blend the local panel designs globally. The blending process is accomplished using the edit distance between individuals of a population and the set of migrants from adjacent panels. The objective function evaluating the fitness of designs is modified according the severity of mismatches detected between neighboring populations. This lays the groundwork for natural evolution to a blended global solution without leaving the paradigm of genetic algorithms.

Carl Gussenbauer (1842-1903), known for many contributions to surgery, should also be noted prominently in the list of pioneers of pancreatic surgery. His successful performance of external drainage for a pancreatic cyst in 1882 was the first planned pancreatic operation. Although pancreatic surgery had been developed in animal models during the seventeenth century, surgery of the human pancreas was practically nonexistent owing to the dismal results seen with incidental pancreatic operations done early in the nineteenth century. Gussenbauer's procedure was a significant advance, representing a safe and effective solution to the pancreatic cyst problem. Gussenbauer's external drainage procedure remained the gold standard for treating pancreatic cysts until the 1920s and was still a widely practiced therapeutic option until the 1950s. With his discipline, insight, and innovative thought, Gussenbauer initiated the modern era of pancreatic surgery.